Chronic Diarrhea

Approach to Chronic Diarrhea
Presented by
Dr Gul Jabeen, PGR1, MD
Dr Mamoona Feroz, PGR1, MD
UCHS & The Children’s Hospital, Lahore
CASE SCENARIO
 A15 montgs old child presented with c/o failure to

thrive, increasing lethargy, pallor, abdominal
distension, diffuse crampy abdominal pain and loose
stools 5 to 6 episodes per day for last 6 months. His
growth curve is flattening
Case scenario
 A15 months old child presented with c/o failure to

thrive, increasing lethargy, pallor, abdominal
distension, diffuse crampy abdominal pain and
loose stools 5 to 6 episodes per day for last 6
months. His growth curve is flattening
 Case of Chronic Diarrhea

DIARRHEA
 Passage of 3 or more Loose or liquid stools/ day,
ACUTE DIARRHEA
acute onset
Lasts 1-2 days
Goes away on its own
 Chronic Diarrhea
Stool volume >10g/kg/day for >4 weeks in infants and toddlers
OR
Stool volume >200g/day for >4 weeks in older children
 Persistant diarrhea
acute onset diarrhea, > 3 episodes /day, persist for >

14 days
Pathophysiology of Chronic
Diarrhea
Osmotic- due to unabsorbed nutrients in intestinal lumen
intestinal damage(enteric inf)
decrease absorptive surface(celiac disease)
Enzyme deficiency(lactase deficiency)
decreased Intestinal transit time(functional diarrhea)
Nutrient overload(overfeeding, fruit juice)
 Secretory- Inhibition of Na /Cl absorption in enterocytes
Active electrolyte and water flux towards intestinal Lumen
e.g bacterial toxins(cholera, E. Coli) , congenital secretory diarrhea, VIP
secreting tumors.
 Inflammatory- IBD
 Motility ddisorders- hyperthyroidism
OSMOTIC VS SECRETORY
DIARRHEA
Osmotic Secretory
Reducing Substances Positive Negative
Stool pH <5 >6
Stool Na+ <70meq/L >70meq/L
Response to Fasting Diarrhea stops Diarrhea persists
Stool volume Less massive Large amount
Stool osmolar Gap >100mosm/kg <50mosm/kg
Stool osmolar gap = 290 mOsm/kg – 2(Na+ k)

Approach to chronic diarrhea
 History- AGE
Early infancy Late infancy- School age Independent
2yrs and of age
adolescent
CMPA Celiac Giardiasis Celiac
Postenteritis Postenteritis IBD IBS
lact-ose lactase def
intolerance
1° lactase def. Toddler’s D Laxative abuse
Immunodeficien Giardiasis Cystic Fibrosis
cy
GI CF IBS
malformation
Congenital CHO CMPA Immunodeficien
malabsorption cy
History – cont’d
 Gender- CMPA and IBD-more common in males

 Socioeconomic –poor and developing countries
infections are more common
 Antenatal History
polyhydramnios+- family hx+-consanguinity=CDDs,
CF
 Onset- Acute but protracted course=
postenteritis diarrhea, 2° lactase def, SIBO
HISTORY-cont’d
 Stool history-
a) Frequency and consistency- dehydration status,
nocturnal frquency(to rule out any organic cause) , stool
vol/day
b) Odourless blood tinged- shigellosis,
Compylobacter, salmonella, E. Coli
c) Blood stained+mucoid- CMPA
d) Blood in stools- IBD
e) Large vol, frothy, bulky, greasy(steatorrhea)
– celiac, CF
f) Explosive watery diarrhea after milk-
lactose/CHO intolerance
History-Cont’d
 DIETETIC HISTORY- Allergy(CMPA), specific food
intolerance(Gluten, Lactose), overfeeding(fluids
>150ml/kg/24hr,undiluted fruit juices/conc. Formula feed)
 ASSOCIATED SYMPTOMS-
1. Associated with weaning, abd distension,Failure to thrive,
Pallor, skin rash= CELIAC DISEASE
2. Recurrent respiratory inf-=CYSTIC FIBROSIS,
IMMUNODEFICIENCY
3. Eczema+Asthma+-rash=EOSINOPHILIC ENTERITIS, CMPA,
4. Infant with severe perioral and napkin
dermatitis=ACRODERMATITIS ENTEROPATHICA
5. Increased skin pigmentation, no correlation with parent’s
complexion- ADDISONS
HISTORY- cont’d
6. Fever+mucoid/Blood in stools, joint pain, severe abd. Pain, oral
ulcers, weight loss= IBD
7. Headache+mood changes+crampy abd pain/discomfort+
aggravated by food and relieved by defacation+diarrhea
alternates with constipation= IBS
8. NO symptoms except diarrhea in an otherwise well child(No
dehydration, normal anthropometric measures) +No night time
defacation= TODDLER’S DIARRHEA
9. Generalized lymphadenopathy +fatigue+weight loss=HIV
10. h/o prologed antibiotics= PSEUDOMEMB. COLITIS.
EXAMINATION
 ANTHROPOMETRIC MEASURES – to assess severity of
diarrhea and its chronicity. If Normal weight and
growth=functional diarrhea
1. height
2. Weight
3. Weight for height
4. MUAC
5. Triceps skin fold thickness
Examination-Cont’d
 GENERAL PHYSICAL EXAMINATION-

1. Pallor – CF, Celiac, IBD
2. Fever-CF, IBD
3. Clubbing-IBD, CF, Celiac
4. Oral ulcers-IBD
5. Oral pigmentation-Addisons
6. Perioral Rash-ACRODERMATITIS ENTEROPATHICA
7. Arthritis-IBD
8. Ear Effusions and adenoid facies-CF
A. Perioral rash B. Napkin rash
(acrodermatitis enteropathica)
Oral ulcers in IBD
Dermatitis herpetiformis-Celiac
disease
Hyperpigmentation-Addison
INVESTIGATIONS
 Stool Examination
1. naked eye appearance-formed/semiformed/colour/smell
2. Pus Cells- colonic disease e.g Chron’s
3. Occult Blood- IBD
4. WBC-eosinophils (CMP intolerance)
5. RBC – IBD
6. Mucus – CMPA
7. Reducing substances – CHO maldigestion/malabsorptions
8. pH- osmotic causes(lactose intolerance)
9. Stool electrolytes- secretory causes
10. Ova/cysts- Giardia Lamblia
11. Culture/PCR- cryptosporidium, yersinia
12. Inflammatory Markers- fecal calprotectin, lactoferrin(colitis)
13. fat globules-steatorrhea celiac diseases, cystic fibrosis
INVESTIGATIONS-cont’d
14. Fecal alpha 1 antitrypsin excretion test- PLE, suggests a mucosal disorder-
elevated FA1AT in Crohn’s and celiac but not in CF or CLD
15. Bile acids – in SBS, ileal resection
16. fecal elastase level- exocrine pancreatic deficiency/CF
 BLOOD
1. FBC – anemia
2. ESR- Chronic infection, IBD
3. LFTs- albumin, total protein
4. electrolytes urea creat- degree of dehydration
5. TTGs (IgA) – celiac serology
6. Immunoglobulins – immunodeficiency
7. HIV SEROLOGY - HIV
INVESTIGATIONS- cont’d
 IMAGING
1. USG /CT ABDOMEN- liver and pancreatic etio
2. Barium meal & small böwel follow thru- structural abn,
congenital SBS
3. Capsule Endoscopy – structural changes, inflammation,
bleeding (smart pill measures pressure, pH and motility as
well)
4. Bone Age- Delay in skeletal development
 Small Bowel Biopsy
celiac(gold standard) , Mucosal enzyme deficiencies
 Sweat Cl test – CF
 Hydrogen Breath test- CHO malabsorption
Treatment
General supportive Nutritional Elimination diet Medicications
measures Rehabilitation
Fluid and electrolyte (based on clinical and Gluten Depending uopn the
support as the cause biochemical Lactose cause-
of death is usually assessment) Cow Milk i) antibiotics-inf
dehydration i) Balanced caloric Depending upon the ii) Immunosupp.-IBD
intake cause iii)Antisecretory
ii) Avoid refeeding agents-racecadotril
synd iv) Somatostatin
iii) Feed-acc to analogues-octreotide-
intestinal NE tumors
absorption
capacitY. For
functional
diarrhea(4F
principle)
iv) Micronutrient &
vitamins-e.g zinc,
vit A, D
v) Probiotics-
Case scenario-how to approach
 A 15 months old child presented with c/o failure to thrive, increasing

lethargy, pallor, abdominal distension, diffuse crampy abdominal pain
and loose stools 5 to 6 episodes per day for 6 last months. His growth
curve is flattening
 DO YOU WANT TO KNOW FURTHER?

History
 ON probing out further History

 Age of onset-9 months
 5-6 episodes/day of large volume, frothy, greasy stools(steatorrhea), non-bloody
 Associated with :
failure to thrive, child was growing well before that
pallor,
abdominal distension
 No h/o fever, Blood in stools, no h/o recurrent chest infections, no h/o joint pains and
oral ulcers, no significant drug history
 No h/o similar illness in family
 Patient was on breastfeed, weaned at 8 months of age along with introduction of top
feeding
Examination
 On examining the patient

 Length=68cm
 Weight=7kg
Both are below 2nd centile
 GPE
Pallor+
Clubbing+
Distended abdomen+
Atrophied muscles
No pedal edema
 Systemic examination is unremarkable
Differential diagnosis
 Celiac disease
 Giardiasis
 CMPA
Investigations
 Stool Examination
Grade 3, frothy, foul smelling
Fat globules +ve
Occult blood – ve
WBCs – ve
RBCs - ve
Pus cells – ve
Ova/cyst – ve
Culture – ve
Labs
 CBC-
Hb 8.7
TLC 11
Platelets 435
MCV,MCH and iron studies normal
 Celiac serology
Total IgA Normal for age
Anti TTG IgA positive >10 times
EMA positive
HLA DQ2 DQ8 positive
Diagnosis
CELIAC DISEASE
Algorithm for diagnosis of Celiac
Disease
Specific Treatment
 Gluten free diet

Take Home Message
 Its very important to diagnose and treat

chronic diarrhea Earlier as it leads to
malnutrition which further makes the child
prone to get infection and increased morbidity
and mortality as well as increase burden on
healthcare system.

Chronic Diarrhea

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Chronic Diarrhea

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Approach to Chronic Diarrhea

 A15 montgs old child presented with c/o failure to

 A15 months old child presented with c/o failure to

 Case of Chronic Diarrhea

 Passage of 3 or more Loose or liquid stools/ day,

acute onset diarrhea, > 3 episodes /day, persist for >

Stool osmolar gap = 290 mOsm/kg – 2(Na+ k)

 Gender- CMPA and IBD-more common in males

 GENERAL PHYSICAL EXAMINATION-

 A 15 months old child presented with c/o failure to thrive, increasing

 DO YOU WANT TO KNOW FURTHER?

 ON probing out further History

 On examining the patient

 Gluten free diet

 Its very important to diagnose and treat

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